I returned back to California after a wonderful and relaxing two weeks at my parents’ home in Kansas only to get a nasty, nasty bout of gastroenteritis (think stomach flu symptoms) two days ago.

Boy was that a long two days.

I’ll spare you the fluid-losing details, but suggest that for any South Park fans out there, I could have easily been featured in an episode. (Being the cautious optimist that I am, however, I will admit to getting a great abdominal workout from the wretching. Reverse peristalsis is pretty amazing.) After multiple bouts, feeling progressively worse, and progressively more light-headed standing up, I finally gave in and the bf drove me to the ED (Emergency Department–the more PC term for Emergency Room). I was hesitant at first, thinking I was somehow weak for wanting to see a doctor, or worrying that I was overusing the health care system while feeling completely rotten. Only in America, folks.

I was actually relieved when the triage nurse told me “I looked like crap” (we were on friendly terms, she probably doesn’t say that to everybody). I was treated really well, and after 2 liters of normal saline, 5mg of phenergan which made me really drowsy but didn’t fix my nausea, and 5mg of reglan that did the trick, I was released, 4 hours later. It’s amazing how much better you can feel after just getting rehydrated.

This isn’t a piece about health policy, or insurance, or lack of it, although it certainly could be. It’s just a reminder to those that are healthy, including my now recovering self: appreciate what you’ve got. I never do, and I will probably forget to. And to those that are ill: may you get well soon.

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I’ve been in contact with a really great Medicare patient advocate for the state of Arizona, and he’s filled me in on why some drugs aren’t listed in the Medicare Drug Calculator :

In your tutorial , you mention that you have questions with the “Enter My
Medications” section. First, the Federal legislation expressively
prohibited Medicare Part D from providing barbiturates and benzodiazepines,
so they won’t show up. Second, an approved plan is only required to provide
two drugs in each treatment category, so many drugs are not on many of the
formularies, although they are also required to provide “substantially all”
drugs available for the treatment of Cancer, AIDS, and a list of other
conditions.

As all of us who’ve used the Plan Finder know, the prescription information
that the person provides us (even with their prescription bottles in front
of us or a pharmacy printout) doesn’t always match what’s available in the
Plan Finder’s prescription drug drop-down lists. A weird example is that I
have sometimes found a brand name only by going to the name of the generic,
and vice versa.

There is a significant challenge to us who don’t have a medical background.
I can sometimes narrow the specific form of a drug down by going to
http://www.rxlist.com/ and finding how the drug is provided, as I don’t have
a current PDF. As a fictional example: I find in the drop-down list that
there are both an “EX” form of a drug and a “TG” form. Looking at this
website (or PDR, or whatever), I see that the “EX” is available in 2.5, 5,
and 10 mg tablets, whereas the “TG” form is in a 10 ml vial, and the
prescription that the person is taking is 5 mg.

I always tell the person being screened when there is uncertainty as to one
of their prescriptions or when I have to leave a drug off the list. I
recommend that they contact the company(s) directly and find out how those
prescriptions will be handled, before enrolling.

Also, here’s a list he sent me of drug classes that have to covered under Medicare Part D:

REQUIRED COVERAGE FOR “ALL OR SUBSTANTIALLY ALL” MEDICATIONS FOR:

• Cancer medications
• HIV/AIDS treatments
• Antidepressants
• Antipsychotic medications
• Anticonvulsive treatments
• Immunosuppressants

(source: CMS webcast PowerPoint slide 4, 9/28/05)

MEDICATIONS EXCLUDED FROM COVERAGE UNDER MEDICARE PART D:
Drugs for:

• Anorexia, weight loss, or weight gain
• Fertility
• Cosmetic purposes or hair growth
• Symptomatic relief of cough and colds
• Prescription vitamins and mineral products
• Except prenatal vitamins and fluoride preparations
• Non-prescription drugs
• Barbiturates
• Benzodiazepines

(source: CMS 2005 REACH training, Module 10, May 29, 2005, PowerPoint, p.
59)

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Syndney Smith, author of Medpundit, is so out of touch with medical students (and probably the future generation of doctors) it’s not even funny:

Maybe medical schools should treat medical students the way an employer does an employee – make attendance count, and have quarterly evaluations of behavior in addition to grades. But do it for everyone, not just for the problem students.

The scary thing is, I can’t tell she’s the exception or the norm. Doctors? Doctors? Bueller? Bueller?

Make attendance count? Have behavior evaluations? I’m pretty sure I signed up for medical school, not choir class. I’m an adult. If there’s a problem with my behavior or attitude or professionalism, I expect my preceptors to discuss it with me–or at least bring it up on my formative comments of my clerkship evaluation. I don’t need another hoop to jump through, showing that I go to class and that I’m a caring, respectful, professional guy (I do, and I am, according to my evaluations so far).

That being said, I agree that medical students should be on-time, professional, and working hard. If a student isn’t, it’s a problem, and it needs to be dealt with. That also being said, I’ve seen examples (uncommonly) of attendings and residents act with prejudice, act using stereotypes, or make gross assumptions about patients–so the assumption that a preceptor is necessarily a model of good behavior and professional conduct isn’t all that valid for certain people.

“Attendance” is a problem when one’s classes are broadcast online for classmates who study better at home or want to pause the lecturer to write things down. “Grades” are a problem when they don’t exist at a medical school to begin with.

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I really, really enjoyed Geriatrics. And since medicine is going to practically turn in to geriatrics in a few years when our parents (and maybe you) get older, there are a number of really important things to remember about our elderly loved ones:

• “Elderly.” “Geriatric.” There’s not an age where you become “elderly,” or that you’re “allowed” to see a geriatrician. It’s usually designated as 65, just because that’s when Medicare kicks in, but often it’s a functional status–what can the person do, and what does he or she need assistance doing?
• Falls. Older patients more likely to fall, and their falls are much more dangerous. They are more likely to pass out or faint, because they have less fluid reserves in their bodies, and are often on multiple medications, many of which can cause light-headedness. They also often have less muscle mass, or are in worse shape, or have arthritis making them less steady on their feet. Diabetics can lose nerve sensation, especially in their feet–this includes the nerve sensations that tell their brains where their feet actually are in relation to their legs. And since older folks tend to have more osteoporosis (brittle bones), they’re more likely to break hips, break other bones, rupture veins in their heads, too. Continuing the logic, elderly people are slower to heal and recover, so they have longer hospital stays, more likely to get infections, and more likely to do worse. So we want to keep elderly folks healthy and out of the hospital!
• Incontinence (losing control of your bladder or bowels) is common in the elderly, too–but often can be fixed or improved with medications.
• It’s important to talk about advanced directives with older patients, or durable powers of attorney; this lets doctors, nurses, family members, and friends know what the patient wanted done, and what he or she didn’t want done. This respects the patient’s wishes to the best of our ability, and allows family and friends to have one less thing on their mind during a serious illness or terminal illness.
• Depression is common in the elderly, and can present differently in the elderly than in younger patients. Symptoms can be memory problems, thinking problems, fatigue, loss of interests–which can sometimes be confused with dementia (like Alzheimer’s disease). Isolation can also be a problem–when people lose their loved ones they’ve depended on their entire lives, they may not want to meet new people or leave the house.
• Functioning: it’s important for physicians to try to get a sense of what an older patient can and cannot do. These are known as ADLs (activities of daily living) and include dressing, feeding, showering, toileting, etc. Instrumental ADLs are other activities that are important for daily functioning in our society–going shopping, balancing a checkbook, doing the cleaning, cooking, etc.
• And a ton more. Stay tuned for tomorrow.

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Today is one of those days that makes me want to move to Canada, France, Spain, or Great Britain, because I’m just utterly disgusted by the Almight Dollar. I’m probably mesmerized by dreams of a greener grass, but today I’m willing to risk it–the weeds we’ve got here are downright rotten .

So we start off with Health Care Renewal’s postings about for-profit institutional review boards (the committees that are supposed to protect you and me from unethical trials like the Tuskegee experiements) and a Bloomberg article describing illegal immigrants desperate for cash being recruited for experimental drug trials . I’m *sure* they’ve all been adequately consented, and their translated consent forms have been approved. By a for-profit institutional review board. Now even Hopkins is using for-profit review boards. ( In case you were wondering by bioethicists haven’t been up in arms about this. ) The whole *point* of an IRB is that it’s supposed to be objective. It’s supposed to be free from outside influences that may skew the committee in one way or another. But *paying* them, oh no, that’s fine. He who pays the piper calls the tune.

And then I go read Kate’s find that we’re wasting hemorrhaging (that means we’re really wasting) money on the new Medicare Drug benefit . Had we just expanded the VA system, senior medications could have been automatically available and at hundreds of dollars per year of savings. (This matters a lot when you’re on a fixed income.) Note: ask your doctor if there are alternatives to the medications you’re on. For example, the “Protonix” example given could be changed to omeprazole (Prilosec), a much cheaper alternative drug in the same class as Protonix and nexium.

And then to top it all off, I go see Syriana. A perfect end to a anti-American day.

I’m a firm believer in the mantra that you can judge a society by it treats its most vulnerable members, and frankly America, we’ve earned an F.

(That’s with the grade inflation.)

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